Status of Health and Medical Care in India

:
A Macro Perspective

Gopal Kadekodi Keerti Kulkarni

Series Editors: Aasha Kapur Mehta, Pradeep Sharma Sujata Singh, R.K.Tiwari P Panchamukhi .R.

2006

Economic Reforms in India: Pro-poor Dimensions

Table of Contents

1 2 3 4 5 6 7

The Context of Economic Reforms in India Analysis of Public Expenditure on Health and Medical Care in India Analysis of Private Expenditure on Health and Medical Care in India A Close Look at Health Care Performance and Processes in India Linking the Performance and Process Inputs of the Health Sector Production and Consumption Linkage Analysis of the Health Sector Conclusions Annexure : Broad notional definitions and norms for setting up of Health Facilities References

1 4 8 12 17 26 31

33 34

Economic Reforms in India: Pro-poor Dimensions

List of Tables, Boxes and Figures
List of Tables
1. 2 3. 4. 5. 6. 7. 8. 9. 10. 11. Pattern of Public Expenditure on Health Care Per Capita Public Expenditure on Health and Family Welfare Per Capita Personal Consumption Expenditure on Medical and Health Care in India Pattern of Private Expenditure on Medical and Health Care (Rural) Pattern of Private Expenditure on Medical and Health Care (Urban) Rural Income Distribution Pattern of Expenditure on Medical Care Health Performance Indicators - All India Level A Comparative Picture Among Developing Countries Human Capital Inputs in Health Sector - All India Level Facilities and Infrastructure Inputs in the Health Sector: All India Level Linkages between Health Sectoral Growth in India 5 6 9 10 10 11 13 14 14 15 18 19 21 27 28 29 30

12a. Correlations between Health Sector Composite Indices 12b. Macro-Econometric Model of Health Sector 13. 14. 15. 16. Backward, Forward, Total Production Linkage and Final Demand Linkage Indices Service and Utility Sectors Changing Structure of Inputs into Medical and Health Sector Changing Structure of Inputs into Drugs and Pharmaceuticals Sector Imports into Health Related Sectors

Boxes
1. 2. Matrix of Macro-structural Linkages Health Sector Related Indicators at the Macro-level 2 12

Charts and Figures
Chart A: Health Infrastructure Over the Years Chart B: Health Manpower Over the Years Chart C: Health Performance Over the Years Figure 1: Central Revenue Expenditure on Health Sector as % of GDP 20 20 20 22

Figure 2 : States’ Revenue Expenditure on Health Sector as % of GDP Figure 3 : Central Revenue Expenditure on Health Sector as % of Total Revenue Expenditure Figure 4 : States’ Revenue Expenditure on Health as % of Total Revenue Expenditure Figure 5 : Per Capita States’ Revenue Expenditure on Health & Family Welfare in Constant Prices Figure 6 : Per Capita Central Revenue Expenditure on Health & Family Welfare in Constant Prices Figure 7 : Per Capita Private Expenditure on Health & Medical Care in Constant Prices Figure 8 : Per Capita Private Health Expenditure as % of PFCE

22 22 23 23 23 24 24

Status of Health and Medical Care in India:
A Macro Perspective
Gopal Kadekodi, Keerti Kulkarni*

1
The Context of Economic Reforms in India
The economic reforms process was set in motion in India in 1991. In a widely circulated document from the Ministry of Finance, Bhagwati and Srinivasan (1993) summarised the rationale for such a reforms process for the benefit of the public. Some excerpts are important and are given below. ‘The economic reforms initiated by the government in June 1991 have an excellent rationale. The ‘macroeconomic’ situation, both external (the balance of payments) and internal (the fiscal deficit), was unsustainable. The cutting of developmental expenditure appears to us to be little beyond what appears prudent: later on this may compromise growth, so the government needs to examine this question carefully. On the other hand, the Finance Minister has been accused of cutting ‘social expenditure’, thus stabilising the economy at the expense of budgetary cuts in spending on the poor.’ (p. (ii) of the report). While arguing for economic reforms, Bhagavati and Srinivasan have warned of the need to maintain longterm development expenditure. This was followed by a major study by Joshi and Little (1996). After arguing in favour of all the reforms between 1991 and 1996, they
*

seem to agree that something must be done for the poor. To quote: ‘However, the major reforms we have applauded or advocated may have serious differing effects on different social and economic classes. These, especially the effects on the poor, cannot be ignored. Indeed the objective of any reform must be to benefit society, and this surely precludes reforms which harm many poor people belonging to that society.’ (p. 219) ‘In the long run, expenditure on primary education and primary health care may be more poverty-reducing than other more immediate measures - provided always that the economic, social, and legal systems are not biased against employment.’ (p. 243) The tone of the emphasis on the process of economic reforms as the pace-setter in development has been changing over the last decade. This debate is very widely documented in various studies and publications (Guhan, 1996; Gupta, 1995; Seeta Prabhu, 1994; Ahluwalia and Little, 1998; Srinivasan, 2000) In particular, the effects of

The present paper is the outcome of a detailed empirical exercise carried out by the Centre for Multi Disciplinary Development Research (CMDR), Dharwad as part of its UNDP sponsored project “Economic Reforms and Health Sector in India”. The views expressed in this paper are those of the authors and do not necessarily reflect the views of GOI, UNDP, IIPA or the collaborating institutions.

1

Status of Health and Medical Care in India: A Macro Perspective

the reforms process on the social sector in general, and on the health sector in particular, have been analysed by a number of scholars who have exercised their minds (Sengupta, 1996; Duggal, 1997; Economic and Political Weekly Editorial, 1992; Panchamukhi, 2001). One of the most recent views on this link between economic reforms and the health sector is available from the following excerpts from Dreze and Sen (1995:13-14): ‘…Bhagwati and Srinivasan’s (1993) lucid discussion of the challenge of economic reforms is entirely silent on the subject of education and health….Education and health can be seen to be valuable to the freedom of a person in at least five distinct ways: Intrinsic importance, instrumental personal role, instrumental social role, instrumental process role, and empowerment and distributive role’ No wonder, Srinivasan (2000) in his most recent book writes that ‘we cannot any longer afford to exclude health and education from the reform agenda. They have to become an integral part of it’ (ibid: p. 45). Therefore, this study aims at putting the health sector back in the mainstream of the reforms process in India. It examines the government’s role, the growth of privatisation and the macro-links between the health and other sectors. In talking about macro-economic links and activities, ‘health and medical’ is treated as a social sector, as are education, real

estate and housing. According to the Central Statistical Organisation (CSO) it includes all medical and health services, as deliverable to the people. The sector is made up of activities emanating from professional and research institutions, hospitals, and clinical services rendered by the medical professionals for the better health care of people of the country. Drugs and pharmaceuticals is another sector, which is very closely linked to the health sector. It is defined as the manufacture of drugs and medicines including allopathic, ayurvedic, unani, homeopathic and others. Basically this sector deals with production of drug intermediates, formulations, medicines and medical accessories (and not retailing).1 Both these sectors (except retailing) are very closely linked to several other macro-economic sectors in the following ways (also see Box 1): Both sectors require inputs from various other sectors of the economy in their production and service activities and in maintaining activities such as providing advocacy, preventive, curative and promotive health services. The inputs for these sectors basically include chemicals, herbal and medicinal plants and animals, human capital in the form of medical professionals, practitioners, medical workers, technicians and scientists, and infrastructure such as hospitals, laboratories, medical instruments, bio-chemicals, radiological equipment, etc.

Box 1: Matrix of Macro-structural Linkages
Health Related Sectors Receiving Inputs From Providing Inputs and Services To Importing Items Such As Exporting Items Such As

Medical and Health Services Sector

Sectors such as Drugs and Pharmaceuticals; Transport; Electricity; Communication; Trade; Electrical appliances; Medical Human Resources and so on Trade; Chemicals; Transport; Electricity; Plastic: Technical Human Resources and so on

Treating people and providing health and medical care; providing services to a large number of other production sectors such as Railways, Defence, etc. Supply of drugs and pharmaceuticals to the Health sector

Chemicals and drugs; electronic and electrical items

Medical manpower such as doctors, nurses and physiotherapists.

Drug and Pharmaceutical Sector

Plastics, chemicals, drug intermediaries

Drug intermediates, chemicals and drugs.

1

Further analysis at the state , regional , and district level, and even village level linkages is addressed separately in other papers from CMDR.

2

The Context of Economic Reforms in India

Broadly speaking all these can be grouped as (1) intermediate inputs, (2) capital inputs and (3) human resource inputs. Both provide services and products for many other sectors of the economy, in the form of medical and health care to people. These sectors depend upon the external (i.e., trade) sector for the import of materials, technical skills and other knowledge. They may also be exporting drugs and pharmaceuticals, medical assistance and technical/medical skills. Within this framework of sectoral linkages, this paper analyses these two sectors at the macro level.2 The macroeconomic analysis is framed in the context of the economic reforms process, started in India in 1991. The paper addresses the following major questions: Have the governments at the central and state levels significantly changed their pattern of allocating financial resources to the health and medical care sector?

The reforms process is likely to reduce the role of the state in the management of the economy’s investment activities in general, through the withdrawal of public investments and by allowing the private sector to take over some of the investment and management activities. However, being part of the social sector of the economy, healthcare may have its own public good characteristics, making it necessary to move in this direction in a calibrated manner. Have the people of the country accepted privatisation in the health care sector? In terms of affordability and acceptability, is private medical care a good substitute for the public health care management? How has the health and medical care sector performed in the post 1991 period as compared to the previous period, both in the public and private domains? What lessons do we have in the liberalised (or more generally referred to as the globalised) situation? Have the export and import linkages shifted significantly to increased exports and imports or have they shrunk in the post 1991 period?

2

As one goes beyond the macro level, to the micro level, it is more and more difficult to get the disaggregated information. For instance, do we know how many patients in India are financed by relatives, as against by insurance schemes, for tuberculosis treatment?

3

Status of Health and Medical Care in India: A Macro Perspective

2
Analysis of Public Expenditure on Health and Medical Care in India
Even today, India is a mixed economy in many walks of life, particularly in the health sector (Baru, 1995). Both the central and state governments spend in the form of capital resource allocations and revenue expenditure on the health sector. How is public expenditure related to health care delivery in India? It is not easy to find the answer to this question in an economy in which a mix of public and private health delivery systems function simultaneously3 ; even without referring to indigenous knowledge and direct access to medical care in kind through the supply of herbal and medicinal plants and roots.4 Nonetheless, the broad channels or groups that incur monetary expenses on health and medical care are: The state (central and state governments) through public expenditure, and The people themselves as part of their personal expenditure.5 Public expenditure consists of all the government expenditure on health and family welfare, at the central and state government levels: on medical education, research, hospitals, Public Health Centres (PHCs), Auxiliary Nurse Midwife (ANM) services and so on. This also includes, by definition, the government expenditure as subsidy. Examples are, subsidy through Central Government Health Scheme (CGHS), medical reimbursements etc. Tables 1 and 2 present the pattern of the central and state governments expenditure in per capita and percentage of GDP terms at con3

4

5

As one goes beyond the macro level, to the micro level, it is more and more difficult to get the disaggregated information. For instance, do we know how many patients in India are financed by relatives, as against by insurance schemes, for tuberculosis treatment? According to the National Biodiversity Strategy and Action Plan, about 40% of medical requirements in India are directly met from biological resources (herbal and medicinal plants and animals). This is analysed in the next section

4

Analysis of Public Expenditure on Health and Medical Care in India
Table 1: Pattern of Public Expenditure on Health Care Revenue Expenditure Year Central State Capital Expenditure Central State

As percent of As As As percent of As percent of As As percent of As Total Revenue percent Total Revenue percent Total Capital percent Total Capital percent Expenditure of GDP Expenditure of GDP Expenditure of GDP Expenditure of GDP 0.729 0.788 0.8 0.756 0.718 0.602 0.71 0.582 0.643 0.549 0.643 0.602 0.647 0.651 0.685 0.839 0.834 1.026 1.193 0.088 0.087 0.097 0.093 0.096 0.09 0.006 0.095 0.103 0.104 0.103 0.093 0.099 0.1 0.1 0.121 0.119 0.14 0.162 9.39 9.862 9.94 11.302 9.765 9.846 9.805 9.621 8.728 9.058 8.672 7.904 8.062 8.314 8.08 8.022 7.495 1.136 1.176 1.262 1.301 1.327 1.38 1.435 1.481 1.292 1.331 1.303 1.232 1.23 1.241 1.196 1.156 1.102 0.083 0.109 0.088 0.013 0.067 0.027 0 0.102 0.077 0.073 0.006 0.069 0.037 0.036 0.207 0.052 0.154 0.077 0.088 0.007 0.009 0.007 0.001 0.006 0.002 0 0.006 0.005 0.005 0 0.004 0.002 0.002 0.009 0.002 0.006 0.003 0.003 0.312 0.359 0.492 0.362 0.371 0.436 0.417 0.39 0.315 0.306 0.372 0.388 0.379 0.365 0.418 0.451 0.019 0.02 0.022 0.02 0.019 0.02 0.021 0.016 0.013 0.012 0.015 0.014 0.013 0.014 0.014 0.013

1980-81 1981-82 1982-83 1983-84 1984-85 1985-86 1986-87 1987-88 1988-89 1989-90. 1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99

Note: Data regarding health sector expenditure of the central government relate only to developmental expenditure. Source: RBI Bulletin and Currency and Finance various issues

stant 1993-1994 prices. Three distinct indicators of public expenditure are analysed. State and central government expenditure on health care, as a percentage of their respective total governmental budgets, State and central government expenditure expressed as a percentage of the GDP (in constant prices), Per capita public expenditure on health care by central and state governments (in constant prices). It is important to note here that the share of public expenditure on health and medical care (i) out of total public expenditure and (ii) as a ratio of the GDP are two important macro-economic fiscal indicators. The per capita public

expenditure allocation however, is a useful indicator, but only in juxtaposition with per capita private expenditure. It will then reflect the degree of privatisation in the economy. The public expenditure over the last two decades on this sector shows several distinct patterns, which are worth noting. Reflections on per capita Revenue Expenditure on Health and Medical Care The per capita revenue expenditure by the central government has shown a slow increasing pattern. It rose from Rs. 1.59 in 1980-1981 to Rs. 3.78 in 19961997 registering an annual growth rate of 5.23 percent. The per capita total revenue expenditure by all the states
5

Status of Health and Medical Care in India: A Macro Perspective
Table 2: Per Capita Public Expenditure on Health and Family Welfare (in constant 1993-94 Prices) (in Rs.) Revenue Expenditure Year 1980-81 1981-82 1982-83 1983-84 1984-85 1985-86 1986-87 1987-88 1988-89 1989-90 1990-91 1991-92 1992-93 All states 20.48 22.07 23.87 26.08 27.02 28.62 30.39 32.02 30.25 32.63 32.95 30.81 31.76 Central 1.59 1.64 1.84 1.86 1.95 1.87 2.46 2.05 2.4 2.55 2.59 2.32 2.55 Capital Expenditure All states 0.12 0.16 0.13 0.02 0.12 0.04 0 0.14 0.11 0.13 0.01 0.09 0.05 0.35 0.38 0.44 0.4 0.4 0.43 0.45 0.38 0.31 0.31 0.37 0.37 Central

ratio of the GDP has remained almost constant through the last two decades. It was 1.136 percent in 19801981 and 1.102 percent in 1998-1999. This gives the impression that the states have been withholding growth in the maintenance of health infrastructure as well as in the development of manpower. Even in the case of central revenue allocations, the growth rate in this sector is just about 3.4 percent.

The capital expenditure on the health sector as a ratio of 1993-94 33.42 2.69 0.04 0.35 GDP reveal two facts. First, 1994-95 34.08 2.85 0.26 0.4 at the central government 1995-96 34.69 3.62 0.06 0.41 level, it fluctuated annually, 1996-97 34.94 3.78 0.18 0.42 slowly declining from 0.007 Note: Data regarding health sector expenditure of the central government relate only to developmental expenditure. Source: RBI Bulletin and Currency and Finance various issues percent in 1980-1981 to 0.003 percent in 1998-1999. Second, for all the states taken taken together was quite high at Rs. 20.48 in 1980-1981, rising to Rs. 34.94 by 1996-1997. This implies a growth together, it has been declining consistently, from 0.019 percent in 1980-1981 to 0.013 percent in 1996-1997. rate of 3.19 percent annually. Taken together at the all India level, the total per capita public expenditure on health and medical care seems to be on the increase from Rs. 22.07 in 1980-1981 to Rs. 38.27 in 1996-1997. Reflections on Public Expenditure on Health and Medical Care, as a proportion of GDP As a percentage of the GDP, the public expenditure on health and medical care reflects some degree of efficiency in maintaining the health delivery system. These ratios were very low at 0.088 percent for central revenue expenditure in 1980-1981. They rose to 0.162 percent by 1998-1999. On the contrary, the revenue expenditure of all the states put together as a Reflections on the Share of Public Expenditure on Health and Medical Care The central and state governments have to make the allocations of their total public funds between the social and other economic sectors in line with the role that the governments have to play in the overall developmental strategies set for themselves. Viewed from this angle, one gets the impression that while the central government public revenue allocations have shown a decline (as a share of total public revenue expenditure) till about 1991-92, they subsequently showed an upward trend. This share was 0.719 percent in 1980-81, and declined to 0.602 percent by 199192 and rose to 1.193 percent by 1998-1999.

6

Analysis of Public Expenditure on Health and Medical Care in India

On the other hand, the states have shown a consistent decline in their share. The share of revenue expenditure of all states in total public expenditure was 9.39 percent in 1980-81, which slowly declined to 7.495 percent by 1998-99. The share was fairly stable till 1987-88, but subsequently started declining. The indicators of shares of capital expenditures reveal that (a) at the central government level they have been fluctuating considerably over the years, but remained around the same level; (b) at the state level, they have fluctuated less and remained fairly constant. The foregoing analysis of the pattern of public expenditure seems to indicate that, while the central government allocations have adhered to providing some degree of support to this vital social sector, the state governments have not been able to maintain allocations at the same rate. This is more pronounced from 1988-1989 onwards. The shrinkages at the state governmental levels in maintaining the rural and urban health delivery systems through PHCs, CHCs, sub-centres etc. are a matter of concern.6 Against these findings, it may be useful to note the observations made by different scholars. Seeta Prabhu (2001:135) notes that ‘State and central governmental allocations to the social sector seem to have gone up from around six percent of aggregate disbursements in the years 1990-91

to 1992-93, to eight to nine percent subsequently. Despite this increase, the government’s expenditure on these sectors constituted less than two percent of the GDP even in the year 1996-1997’. According to her, in states like Maharashtra and Tamil Nadu, revenue expenditure on health and family welfare as a ratio of total revenue expenditure in 1995-1996 was 5.18 and 6.14 percent, respectively (ibid. 185-86) or 0.67 and 1.21 as a ratio of the respective State Domestic Product. One can only say that, in the early 1990s if the share of public allocations to the social sectors showed marginal improvement, this did not get reflected in the health sector, but perhaps was subsumed in education, nutrition, PDS and other social commitments of the government. In another independent study, Berman (1996: 335) shows that in India the public expenditure on health care was just about 1.3 percent of the GDP in 1990-91, while private outof-pocket expenditure is 4.5 percent of the GDP7. This amounts to public expenditure being just about 25 percent and the rest being met through private sources. Krishnan (1996: 944) quoting from a study by Reddy (1995) states that in India public expenditure including preventive care, forms a mere two percent or less of the GDP. Krishnan also says that these are much lower than the rates observed in China and other East Asian countries.

6 7

This issue is addressed in greater detail, in Annigeri (2004). Our own data also show the same.

7

Status of Health and Medical Care in India: A Macro Perspective

3
Analysis of Private Expenditure on Health and Medical Care in India
There are two major sources of information for this at the macro level – the Central Statistical Organisation (CSO) and the National Sample Surveys (NSS). Personal expenditure from both the sources of data refer to the expenditure incurred by the people as personal consumption expenditure. This may be either what they have paid out of their own pockets or through some health insurance schemes. Let us first examine the data from the CSO. In per capita terms, private expenditure will reflect the trend of privatisation as well as the ability (and to some extent) ‘willingness to pay’ for medical care. Table 3 shows the macro-scenario of personal expenditure on health and medical care in India from 1970 to 1999. At the aggregate level, the private expenditure on health care is about 4.39 percent (at current prices) of the total of all private consumption expenditure in India in 1998-99, or about 3.36 percent of the total disposable income of the people of India. These aggregated shares, have, over time, shown a growing trend. Several observations can be made on the basis of the pattern of private expenditure: As a share of total private consumption expenditure, as well as that of total disposable income (not shown in this table), the private expenditure on health and medical care has been consistently decreasing (both at current prices and in constant prices). In constant prices, the share of private expenditure on health care out of
8

the total private consumption expenditure was 3.03 percent in 1980-81, which slowly declined to 2.03 percent by 1996-97. While private expenditure at current prices has shown remarkable growth, rising from Rs. 44.32 in 1980-81 to Rs. 173.42 in 1996-97 (an annual growth rate of 8.9%), if we estimate this in constant prices, it remained at an average of Rs. 44 during the period 1980-97. The average elasticity of private expenditure on health care vis-à-vis total private expenditure before and during the current reforms period is almost the same at -0.046. As a share of disposable income, private expenditure on health care declined from 2.43 percent in 1985-86 to 1.53 percent in 1996-97. The growth rate in private expenditure on health during the period 1971-1996 was just about 0.012 percent; whereas the growth rate in per capita disposable incomes was 0.119 percent. The elasticity of private expenditure on health with respect to disposable income is 0.1019 (=0.0121/ 0.1187) during the same 25 year period, which is much lower than unity, indicating a very slow uptake on the health front, in sharing the responsibility of health care privately.

Analysis of Private Expenditure on Health and Medical Care in India

Table 3: Per Capita Personal Consumption Expenditure on Medical and Health Care in India Year Old Series Prior to Reforms 1971-72 1972-73 1973-74 1974-75 1975-76 1976-77 1977-78 1978-79 1979-80 1980-81 1981-82 1982-83 1983-84 1984-85 1985-86 1986-87 1987-88 1988-89 1989-90 1990-91 Reform Period 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 New Series 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 222 283.98 329.88 370.56 438.03 509.34 222 241.48 262.63 285.57 311.57 334.42 3.43 3.9 4.03 3.88 4.3 4.43 3.43 3.61 3.77 3.82 4.13 4.29 106.69 114.33 124.77 145.82 155.31 173.42 44.34 44.24 44.13 44.14 44.07 43.97 2.37 2.29 2.22 2.29 2.2 2.21 2.4 2.34 2.27 2.19 2.11 2.03 Per Capita Private Expenditure on Health & Medical Care in Rs In Current Prices 13.29 15.26 17.54 20.15 23.14 26.59 30.56 34.66 39.32 44.32 50.4 57.3 65.14 65.93 67.95 69.93 75.64 90.73 93.1 98.69 In Constant Prices 1980-81=100 32.55 34.92 35.31 35.13 34.3 35.37 37.17 38.93 45.87 44.32 44.31 44.28 44.22 44.15 44.1 44.01 43.94 43.94 43.95 43.87 Per Capita Private Health Expenditure as %of PFCE In Current Prices 2.1 2.24 2.18 2.11 2.43 2.74 2.8 2.98 3.2 3.04 3.07 3.25 3.2 3.01 2.89 2.7 2.66 2.82 2.64 2.49 In Constant Prices 1980-81=100 2.46 2.69 2.71 2.75 2.6 2.67 2.66 2.68 3.33 3.03 2.95 2.93 2.78 2.73 2.68 2.6 2.56 2.47 2.41 2.37

Notes: The estimates based on the old series and the new series are not directly comparable. This is because the CSO has revised the methods of estimating national income etc., to a new base year of 1993-1994 from the old method of referring to 1980-1981 as the base. Source : National Accounts Statistics 2000, CMIE

9

Status of Health and Medical Care in India: A Macro Perspective
Table 4: Pattern of Private Expenditure on Medical and Health Care (Rural) Year July-June 88 Jan-Mar 92 Total Medical Expenditure 7.01 12.27 Institutional July 93-June 94 July 94-June 95 July 95-June 96 Jan-Dec 97 Jan-June 98 2.58 3.72 2.44 6.23 6.1 Non-Insti tutional 12.76 11.71 11.56 16.3 14.74 281.4 309.43 344.29 395.01 382.07 Total Consumer Expenditure 158.1 247.21 Institutional 0.92 1.2 0.71 1.58 1.6 Medical Expenditure as % of Total Expenditure 4.43 4.96 Non-institutional 4.53 3.78 3.36 4.13 3.86 Total 5.45 4.98 4.07 5.71 5.46

Source: National Sample Survey, various rounds.

Table 5: Pattern of Private Expenditure on Medical and Health Care (Urban) Year July-June 88 Jan-Mar 92 Institutional July 93-June 94 July 94-June 95 July 95-June 96 Jan-Dec 97 Jan-June 98 5.54 5.28 7.3 12.41 17.62 Non-Insti tutional 15.51 12.28 15.03 20.58 20.1 458.04 508.07 599.26 645.44 684.27 Institutional 1.21 1.04 1.22 1.92 2.58 Non-institutional 3.39 2.42 2.51 3.19 2.94 Total 4.6 3.46 3.72 5.11 5.52 Total Medical Expenditure 8.14 Total Consumer Expenditure 449.93 Medical Expenditure as % of Total Expenditure 1.81

Source: National Sample Survey, various rounds.

However, in the reforms period (i.e., after 1990-91), the per capita private expenditure on health care has marginally declined at a rate of 0.16 percent; but the per capita disposable incomes have been increasing at a much faster rate than in the earlier period. Growth rate of per capita expenditure on health (in constant prices) during 1971-90 was 1.58 percent, and 0.16 percent during 1991-1999. The per capita disposable income growth rate during the period 197191 was 11.17 percent, which increased to 14.23 percent during the period 1991 to 1999. The second important source of data on private health and medical care expenditure is the NSS. On the basis of
10

available NSS data for the recent period, expenditure by individuals on hospitalisation and outpatient expenses visà-vis total private expenditure is compiled on a per capita basis. Tables 4 and 5 show this for the urban and rural areas, at the all India levels. Details of expenditure on medical care are available for the year 1988 and 1992 onwards till 1998. Four major observations can be made on the basis of this data : First, when it comes to expenditure on medical care, there is a significant contrast between the rural and urban populations. On an average the urban population spends a higher amount.

Analysis of Private Expenditure on Health and Medical Care in India

Second, over the years the expenditure incurred by the urban population is rising faster than that for the rural population. It was Rs. 8.14 per capita in 1988, and rose to Rs. 37.72 by 1998. Corresponding estimates for the rural population were Rs. 7.01 and 20.84 respectively.

Table 6 : Rural Income Distribution Pattern of Expenditure on Medical Care Medical Care % of population below poverty line Average Per capita monthly expenditure on medical care Average Per capita total monthly expenditure % share expenditure on medical care Top 10 % Expenditure Class Average Per capita monthly expenditure on medical care Average Per capita total monthly expenditure % share of expenditure on medical care 1992 30.87 2.83 123.8 2.29 10 53.1 588.19 9.03 1998 27.09 7.05 249.99 2.82 10 103.91 895.19 11.61

Third, both in absolute Sources: 1. NSSO, Sarvekshana, various issues; 2. Report of the Expert Group on Estimation of Proportion and Number of Poor (Planning Commission). terms and as a share of total private expenditure, outpatient expenditure is more NSS data for the years 1992 and 1998, two separate questhan the expenditure on hospitalisation. tions are asked.8 How much do the people below povFourth, while the share of medical expenditure in total private expenditure remained fairly constant for the rural population (4.43% in 1987-88, and 5.46% in 1998), for the urban population it escalated from 1.81 percent in 1987-88 to 5.52 percent in 1998. The rate of growth for the urban population was 11.8 percent as against 2.1 percent for the rural population. Clearly, in recent years, the growth of private medical care systems is more visible in the urban areas. Further, during the same period, as a share of total private expenditure, the outpatient expenditure is more than hospitalisation expenditure in both rural and urban areas. There is a significant jump in medical expenditure incurred by the rural and urban population between the 19871988 period to the 1992 period, but after the 1992 period, the trend seems to have stabilised. The pattern of spending on health and medical care also differs by different income or expenditure classes. Using erty line (BPL population) spend on medical care? How much do the top 10 percent of people in the country spend on medical care? The data in Table 6 has been worked out from NSS data for the rural population. In order to estimate the expenditure patterns by the percentage of people, a lognormal distribution is assumed for the medical expenditure as well as total private expenditure data.9 It can be observed from Table 6 that: While the BPL population in the years 1992 and 1998 spent just about two to three percent of their total consumption expenditure on health care; the top 10 percent people spent nine to 12 percent on the same. The per capita expenditure per month on medical care was low for the BPL population in 1992 as well as in 1998 (just about Rs. 2-3 in 1992, and Rs. 7 in 1998). The estimates for the top 10 percent of people for the same period were Rs. 53 and Rs. 104, respectively.

8 9

Expenditure distribution-wise data are available from 1992 onwards. However, this could not be estimated for the urban population in 1992 as such data are not available for the urban population in the 48th Round of NSS (period January-March 1992).

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Status of Health and Medical Care in India: A Macro Perspective

4
A Close Look at Health Care Performance and Processes in India
How do we analyse the linkages between the performance of the health sector in relation to (a) the expenditure by the central and state governments as well as private or personal expenditure on health and medical care; (b) various medical facilities and infrastructure existing in the country in this sector and finally (c) the quantum of medical manpower resources that are available? state governments’ expenditure on health and family welfare) and private expenditure by people has already been presented in Sections 2 and 3 of the paper, as two important indicators of expenditure. As can be seen from Table 7, the birth rate in India has been declining consistently during the last two decades. It was as high as 34 per thousand population in the 1980s and declined to about 26 by the late 1990s. The crude birth rate in India is still quite high compared to countries such as China, Chile and Sri Lanka (Refer Table 8), but the rate of decline has been higher in recent years (from –1.18% in the pre-1990s to –1.42% post 1990s). Compared to many developing countries (also going through the reform process), this rate of decline in birth rate is still moderate. For instance, the birth rate was -3.61

We need to identify the major indicators of performance of the health sector, the health care facilities and infrastructure inputs; and human resources before we answer the above.10 This identification process at the macro level is based, by and large, on the availBox 2: Health Sector Related Indicators at the Macro-level ability of such data over a Health Performance Input or Process Indicators Indicators long period of time. Box 2 Human Resources Indicators shows the major indicators 1. Crude birth rate 1. No. of hospitals 1. No. of Doctors selected for this macro 2. Crude death rate 2. No. of Beds 2. No. of Dentists analysis. Tables 7 to 10 3. Infant mortality rate 3. No. of PHCs 3. No. of Nurses show the corresponding 4. Life expectancy 4. No. of Sub-centres data for 17 years. The pub5. Couple protection rate 5. No. of CHCs lic expenditure on health Note: While all the performance indicators are expressed as rates (except for Life expectancy), the care (i.e., the central and infrastructure and human resource indicators are expressed per million of population.

10

This question is particularly important, since none of them can be captured by any unique indicator, and alternative indicators are not as homogeneous in measurement as health care expenditure. Stated simply, they are just not additive.

12

A Close Look at Health Care Performance and Processes in India

percent in Chile during the 1990-1998 period; –2.28 percent in China; and –2.36 percent in Sri Lanka during the same period (Ashtekar, 1999). The crude death rate has also been declining, from 13 per thousand population in the 1980s to eight per thousand population in the late 1990s. This decline is comparable to countries such as Chile, China or Sri Lanka. As

was the case in these countries, the rate of decline in India has been lower in the 1990s (-2.17%), compared to the pre-1990s -2.38%). It is important to take note of India’s better performance here. Chile for instance, showed a decline in CDR (–0.36 percent) during the 1991-1998 period; China experienced an increase (positive 0.97 percent); and Sri Lanka, a decline(–0.14 percent).

YEAR 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Growth rate before 90’s Growth rate after 90’s Combined growth rate
Notes.

Table 7: Health Performance Indicators - All India Level CBR CDR IMR LE CPR 33.7 33.9 33.8 33.7 33.9 32.9 32.6 32.2 31.5 30.6 30.2 29.5 29.2 28.7 28.7 28.3 27.4 27.3 27 26.404 25.965 –1.18 –1.42 –1.46 12.6 12.5 11.9 11.9 12.6 11.8 11.1 10.9 11 10.3 9.7 9.8 10.1 9.3 9.3 9 8.9 8.9 9 8.23 8 –2.38 –2.17 –2.26 114 110 105 105 104 97 96 95 94 91 80 80 79 74 74 74 72 64.1 63 58.61 55.86 –2.86 –3.99 –3.4 52.84 50.4 54.19 55.4 55.54 56.22 56.89 57.57 57.7 58.3 58.7 59.4 60.8 60.3 62.29 62.97 63.64 64.32 63 65.67 66.34 1.27 1.12 1.16 22.8 23.7 25.9 29.5 32.1 34.9 37.5 39.9 41.9 43.3 44.1 43.6 43.5 45.5 45.8 46.5 45.4 45.4 51.32 52.74 54.17 7.19 2.33 3.78

GPLE 32.16 34.6 30.81 29.6 29.46 28.78 28.11 27.43 27.3 26.7 26.3 25.6 24.2 24.7 22.71 22.03 21.36 20.68 22 19.33 18.66

GPCPR 77.2 76.3 74.1 70.5 67.9 65.1 62.5 60.1 58.1 56.7 55.9 56.4 56.5 54.5 54.2 53.5 54.6 54.6 48.68 47.26 45.83

CBR= crude birth rate per 1000 popn._ CDR= crude death rate per 1000 popn_ IMR= infant mortality rate per 1000 popn_ LE= life expectancy CPR= couple protection rate GPLE is a transformed variable defined as: 85life expectancy GPCPR is a transformed variable defined as:100-cpr Both these indicators created for purposes of further analysis of the sectoral performance Growth rates (in %) are based on exponential growth models Source: Health Monitor 1994 (FRHS DATA)

13

Status of Health and Medical Care in India: A Macro Perspective
Table 8: A Comparative Picture Among Developing Countries CBR Country Chile China Sri Lanka Early 80’s 23 18 28 Late 90’s 18 16 18 80' 7 6 6 CDR Early Late 90’s 5 8 6 68 Early 80’s 69 LE Late 90’s 75 70 73 IMR Early 80’s 32 42 34 Late 90’s 10 31 16

a minimal link with public expenditure pattern, both at the central and state government levels. This requires further analysis with proper identification of the flow of funds to specific health care facilities, amenities and programmes.

Source: Puttaswamaiah S (2004)

A remarkable downward shift has been observed in India in the rate of infant mortality, from 114 per thousand population in the 1980s, to 56 in the late 1990s but it still lags behind countries such as Chile, China or Sri Lanka. However, as compared to its rate of decline (–2.88 percent) in the 1980s and early 1990’s, the rate has dropped significantly in the late 1990s (-3.99%). One of the most striking performances on the health sector front is that of the Family Welfare Programme, though much more remains to be done. The ‘couple protection rate’, which was just about 23 per hundred eligible couples in the 1980s, went up to 54 percent in the late 1990s. The rate however, declined from 7.12 percent in the pre1990s to 2.33 percent in the late 1990s. As against these health status records, the life expectancy (LE) in India has not improved as remarkably as the other performance indicators. For instance, it was 54 years in the early 1980s, which rose to 66 years by the late 1990s. The overall rate of increase is 1.16 percent. By comparison, in countries like China, Chile or Sri Lanka, it is over 70 years. In Chile, LE has grown at 0.29 percent, in China at 0.18 percent and in Sri Lanka at 0.33 percent during the 1991-1998 period. Thus, from the foregoing analysis it seems that during the recent reforms period, India’s performance compares well with a populous country like China or smaller countries like Chile and Sri Lanka, in the area of health care. This seems to be encouraging, but a lot more is needed. The health sector’s performance in India seems to have
14

In planning for this sector at the national level, the following issues need attention based on performance on the health front: The health and medical care sector will have to further gear up to enhance the life expectancy rate in the country. The slowing down of family welfare programmes in the post 1990s should be taken as a warning for future
Table 9: Human Capital Inputs in Health Sector : All India Level

Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Growth rate before 90’s Growth rate after 90’s Combined growth rate

Dentists 8642 8656 8801 8725 9598 9725 9750 9796 10475 11011 10751 11300 19523 21720 23953 25762 27707 2.66 16.8 7.69

Nurses 143883 161044 157372 168024 193907 205489 217375 245386 258167 304137 334900 383632 451240 512135 556859 566213 620361 7.93 10.1 9.8

Doctors 268700 271500 284200 296500 308200 320300 331800 355600 368600 381900 394000 410800 379300 391200 405200 360100 367198 4.12 –1.45 2.45

Source: Health Information – India, MHFW.

A Close Look at Health Care Performance and Processes in India

planning in the health arena. The persistence of the relatively high crude birth rate calls for some more promotive and preventive health care measures in the future. Through providing better health care and enabling transparency and information on the medical front (specifically from curative to preventive and promotive aspects), it is still possible for the Indian population to attain much better health status in terms of birth and death rates. Analysis of the medical manpower resources in Table 9 shows that since the 1990s there has been significant growth in human resources in the dental and nursing sec-

tors in the country, as compared to the previous period. However, as compared to an increasing rate of 4.12 percent in the pre-1990 period, the availability of doctors seems to be slowly declining (at the rate of –1.46% it is marginally declining) during the recent period. Five different health facilities and infrastructure amenities available in the country are analysed in Table 10, at the per capita and total levels. These are the number of hospitals and all other beds, PHCs, CHCs and sub-centres in the rural areas. While there is an increase in numbers over time, the increase is much slower in the 1990s than in the period before. For instance, the growth in the number of PHCs, sub-centres and CHCs has come down drastically from 16.40 percent, 10.30 percent and 18.10 percent in the pe-

Table 10: Facilities and Infrastructure Inputs in the Health Sector - All India Level Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Growth rate before ’90s Growth rate after ’90s Combined growth rate Beds (All) 569495 583773 599074 624769 656850 694121 706471 751091 794712 806409 810548 834650 859640 863969 870161 896875 924409 4.15 1.97 3.12 PHCs 5740 5851 5959 6375 7284 12934 14281 16449 18811 18981 20450 20719 21030 21206 21536 21853 22960 16.4 1.71 9.94 Sub Centres 51405 57975 65643 77236 84590 92483 101549 109644 120767 130336 130958 131464 131384 131586 131795 132778 136800 10.3 0.55 5.88 CHCs 349 471 553 649 761 915 1100 1322 1589 1910 2069 2187 2273 2332 2387 2420 2708 18.1 3.78 12.7 Hospitals 6804 6897 7189 7369 7474 8067 9803 10840 11079 11571 11174 13692 14867 15033 15097 15982 16918 6.72 5.6 6.34

Note: All growth rates are derived from exponential growth functions, expressed in percentages Source: Kadekodi and Kulkarni (2004)

15

Status of Health and Medical Care in India: A Macro Perspective

riod before the 1990s, to 1.71 percent, 5.5 percent and 3.78 percent, respectively, in the post 1990 period. The number of hospitals has been growing at a fairly constant rate (around 5.6% to 6.7%) both before the reforms and during the current period. However, the rate of growth of hospital beds has not been increasing at the same rate as the number of hospitals. Instead, their growth rate has come down in the post 1990s. This

seems to be sending a message about the increased shortage of hospital beds in the current period, as compared to the pre-1990s.11 We have already seen from the analysis of government as well as private expenditure, that there has not been any remarkable shift over the years. Instead, several indicators suggest that the ‘State’ has played a very poor role in the health care sector.

11

At this point, it may be useful to take a look at the norms of health sectoral inputs or allocations. A summary of these are provided in Annexure 1

16

5
Linking the Performance and Process Inputs of the Health Sector
This section attempts to link the various indicators of the health and medical sectors presented in Sections 3 and 4. It tries to answer the following questions: Is there any evidence that with the onset of the economic reforms process in India, the process of health delivery or performance (to be denoted as HP= Health performance) took the course of substituting Medical Facility and Infrastructures (to be denoted as HI= Health infrastructure capital), or replacing the Medical Human Capital (to be denoted as HC= Human capital)? Has the overall health delivery rate been going down vis-à-vis the rate of population growth, particularly after the introduction of the reform process? Treating health and medical care as an indicator of welfare, how does one calibrate the Indian health sector’s performance vis-à-vis the overall indicators of welfare such as GDP growth? These are very fundamental questions and need to be addressed in the context of the reforms process in India at all levels: macro economic and micro (regional, district, or village) levels. For this purpose, a Factor Analysis was carried out. The major steps involved or employed for this exercise are summarised here:
12

In order to get a composite picture of the Health Performance (HP), Health related Human Capital (HC) and Health Facilities and Infrastructures (HI) in India, separate Composite Indices were constructed. While doing so, it is necessary to ensure that all the variables entered in the composite indices are monotonic.12 Observations on all the variables under Health Facility and Infrastructure (Table 10) and Human Capital (Table 9) are monotonically increasing. In the case of Health Perfor mance variables (Table 7) while the CDR, CBR and IMR are declining over the years, the LE and CPR are increasing over the same years. Therefore, for purposes of constructing a Composite Index on HP, a transformation of LE and CPR are made. For this, two new variables GPLE= 85-LE, and GPCPR=100-CPR are considered. GPLE is then interpreted as a gap in full life expectancy of 85 years (normally recommended in HDI computations). Similarly, GPCPR is the gap in achieving 100 percent CPR. Obviously, without any loss of information for the health sector, these two variables are also declining over the years, as are CDR, CBR and IMR (as can be seen from Table 7). However, the declining rates of all these variables are indicative of improvements in health performances over the years.

This is just a mathematical requirement. Otherwise, variables such as CBR and CDR decreasing over the years and CPR increasing over the same years, cannot be added (even after suitable weights obtained from Factor Analysis).

17

Status of Health and Medical Care in India: A Macro Perspective

Next, the Composite Indices on HP, HI and HC are estimated by carrying out a factor analysis (based on Principal Component Method), using all the variables shown in the Tables 7 to 10. In the case of Human Capital (HC) and Facilities and Infrastructure (HI), two different Composite Indices are estimated. They are (a) at the ‘aggregate’ levels as shown in Tables 9 and 10, and, (b) On ‘per million population’ basis. Since the estimated indices monotonically increase from negative to positive values, for purposes of further presentation, a linear transformation of these was done by adding 2.0 uniformly to all the estimated indices, to make them look non-negative.

Note that, with all the five variables under Health Performance decreasing, its Composite Index has also been declining over the years (which, of course, indicates overall improvements in the health sectoral performance). Finally, in order to have an increasing composite index of health performance, the estimated composite index is further transformed linearly as : Final Composite Index for HP=1/[2-estimated composite index]. Note that, there is no loss of information for analysing the HP vis-à-vis HI and HC, under any of these linear transformations. The final set of Composite Indices is shown in Table 11.

Table 11: Linkages between Health Sectoral Growth in India Composite Indices of Health Year Performance (HP) 80-81 81-82 82-83 83-84 84-85 85-86 86-87 87-88 88-89 89-90 90-91 91-92 92-93 93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 0.28 0.27 0.31 0.32 0.32 0.36 0.39 0.42 0.43 0.49 0.56 0.59 0.61 0.7 0.72 0.78 0.86 0.96 1.16 2.01 2.98 0.45 0.56 0.68 0.85 1.02 1.39 1.66 1.97 2.28 2.48 2.55 2.78 2.92 2.96 3 3.12 3.35 0.37 0.46 0.58 0.79 1.01 1.49 1.78 2.19 2.55 2.7 2.65 2.87 2.97 2.89 2.82 2.84 3.04 0.74 0.8 0.89 1 1.19 1.31 1.42 1.65 1.81 2.04 2.19 2.45 2.85 3.2 3.52 3.33 3.62 1.09 1.13 1.1 1.11 1.29 1.32 1.34 1.44 1.53 1.73 1.79 1.99 2.89 3.26 3.56 3.58 3.86 Facility & Infrastructure (HI) Aggregate On per Mill. Popl. basis Human Capital (HC) Aggregate On per mill. Popl. basis

Notes: The Health infrastructure and human capital composite indices are computed both at the total sectoral level as well as on per million population basis. The pattern of the two will remain the same, though the indices will differ.

18

Linking the Performance, and Process Inputs of the Health Sector

The correlation between the three indicators before and during the reforms period is useful for drawing inferences regarding the nature of their linkages. This is shown in Table 12a.

Table 12a: Correlations between Health Sector Composite Indices
Between 1980-90 HP HP HC 0.98 1.0 HC 0.97 0.95 Between 1991-98 HP 0.92 1.0 HC 0.62 0.6 Between 1980-98 HP 0.96 1.0 HC 0.87 0.76

As can be seen from the stylised correlation coefficients in (i) the pre-reforms period, (ii) during the reforms period and (iii) the total period, it can be said that: 1. There is a high association between Health Performance (HP) and Health Sectoral Infrastructure (HI) and Health manpower (HC) in the period 1980 to 1990. This strong link is broken in favour of, ‘between health manpower and health sector performance only’ during the latter period. 2. In the period 1991 onwards, basically it is manpower growth that has kept health performance quite high. As can be seen from Charts A, B and C and Table 11, there seems to be a relationship between the performance and process indicators requiring further analysis. In the light of the questions posed at the beginning of this Section, the following inferences and observations can be made regarding the effect of the reforms process on the health sector in India: Overall performance has doubled during the period 1980-81 to 1990-91. The HP indicator, which was 0.28 in 1980-1981, rose to 0.56 in 1990-1991, but has more than quadrupled in the subsequent reforms period! There may be many reasons for the remarkable performance during the 1990s. Improvements in the health sector being a long run phenomenon, the investments and efforts carried out in the earlier period might be showing positive results now. It is also likely that the remarkable performance during 1991 to 2000 may be due to the type of reforms in the health sector itself. The aggregate health infrastructure growth, as viewed from its composite index HI gives the impression that during the pre 1990-1991 period, it grew fivefold in 10 years (from 0.45 in 1980-1981 to 2.48 by 1990-

1991); but during the period 1990-91 to 2000-01, it increased by just about 35 percent . Therefore, the high rate of health infrastructure development prior to the 1990s is noted. If one considers the aggregate human capital growth, it has shown an increase of about 175 percent during the 1980-1990 period. During the reforms period, over about seven years, it increased by about 77 percent. The growth in infrastructure and human capital suggests different degrees of importance attached to them in different sub-periods. As can be seen from Chart A and Chart B three sub-periods are discernible. For instance, till about 1985, health infrastructure was growing faster than health-related human capital. From 1985 to 1993, the infrastructure growth was slowing down, whereas human capital was growing faster. From 1994 onwards, the health manpower/human capital was growing still faster whereas infrastructure growth was sluggish (even declining in 1994-95 and 1995-96). As can be seen from Chart A till about 1991, the health infrastructure growth was faster than health manpower. Subsequently, the growth in health manpower overshadowed the growth in infrastructure. The remarkable growth of health performance during the 1990-2000 period can be understood then as mainly being due to high infrastructure growth during the pre-1990 period and high growth of health manpower in the post 1990 period. The setback in the growth of health manpower during the reforms period has certainly affected the health sector’s overall performance. Much of the health manpower has either shifted from the public to the private sector during the period, or increasingly migrated abroad.
19

Status of Health and Medical Care in India: A Macro Perspective

Chart A: Health Infrastructure Over the Years

Chart B: Health Manpower Over the Years

Chart C: Health Performance Over the Years

20

Linking the Performance, and Process Inputs of the Health Sector

Public investment and expenditure seems to have had very little influence on the performance of the health sector as a whole. However, it may have played a specific role in certain states or districts, which is a matter for further investigation. This can be stated emphatically on the basis of both central and state level allocations on the health sector vis-à-vis (i) the total budget, (ii) as a share of the GDP and (iii) in per capita terms. Figures 1 to 8 highlight the same. Thus the major conclusions that can be reached are: Budgetary allocations in the health sector played the role of minimal support in the Indian economy, by maintaining it with very little emphasis on the role of the ‘state’ in the wake of economic reforms in India. The qualitative and technical changes that took place in health care facilities and infrastructure and manpower were responsible for the development of the health sector. It may be useful at this stage to link the health performance indicators during both the pre-reforms the reforms periods, with the fiscal reforms indicators analysed earlier. This is attempted with an econometric model of the health sector at the macro level. The following variables are considered in this model13 : PUCE= Ratio of state and central public capital expenditure to total public capital expenditure HC= Composite Index of Health Human Capital HI= Composite Index of Health Infrastructure HP= Composite Index of Health Sectoral Performance D90= ‘Reforms’ Dummy variable, representing the effects of reforms process; it takes a value equal to zero during the pre-reforms period, and equal to unity during the reforms periods.
13

The basic objectives of the econometric model are to study the following: Is there any clear indication that the health manpower or human capital (HC) and health infrastructure developments (HI)) have shown distinct patterns during the two phases of the reforms process, namely before and during the reforms? Is there any systematic relation visualised between health infrastructure (HI) and health manpower (HC) growth? Is there any pattern being followed in allocating public resources to the health sector? Can the overall performance of the health sector (HP) be explained by the health manpower, health infrastructure and public investment policies? In order to study the effects of the reform process itself, a dummy variable D90 is introduced. Alternative forms of the relationships have been estimated and only the statistically significant ones are summarised in Table 12b.
Table 12b: Macro-Econometric Model of Health Sector Explanatory Variables Dependent Constant HI HC AHI Variable term HI -0.81 HC 0.805 HC -0.75 PUCE 0.439 HP -0.54 HP –0.521 1.247* 1.261* 0.562 0.217 * 0.00696 -0.00545 0.0164* -0.82 @ 0.0226* -1.14 0.683* -0.7 -0.112* -(0.09)

D90 1.572* (0.35) 1.424* -0.33

Notes: 1. Figures in brackets under the dependent variables are the R values; 2. Figures in brackets under explanatory variables are estimated elasticities, 3. @: Here, instead of observed HC, estimation from another regression equation is used.

Public Revenue expenditure at the state and central levels was also considered in the model. But no significant econometric relations could be established between this and health performance indicators.

21

Status of Health and Medical Care in India: A Macro Perspective

Figure 1: Central Revenue Expenditure on Health Sector as % of GDP

Figure 2: States’ Revenue Expenditure on Health Sector as % of GDP

Figure 3: Central Revenue Expenditure on Health Sector as a % of Total Revenue Expenditure

22

Linking the Performance, and Process Inputs of the Health Sector

Figure 4: States’ Revenue Expenditure on Health as % of Total Revenue Expenditure

Figure 5: Per Capita States’ Revenue Expenditure on Health & Family Welfare in Constant Prices

Figure 6: Per Capita Central Revenue Expenditure on Health & Family Welfare in Constant Prices

23

Status of Health and Medical Care in India: A Macro Perspective

Figure 7: Per Capita Private Expenditure on Health & Medical Care in Constant Prices

Figure 8: Per Capita Private Health Expenditure as % of PFCE

To summarise, maintaining health manpower growth systematically is crucial for improving the health delivery system in the reforms period. The following conclusions can be drawn on the basis of the econometric model: The reforms process has brought distinct changes in the growth of health manpower and health infrastructure. This is also visible from Chart A and Chart B. The ‘reforms’ dummy variable is significant and has a positive coefficient, indicating a significant shift in these two major performance indicators of the health sector in the reforms period. Secondly, the growth in health manpower and health infrastructure seems to be linked, a fact, perhaps obvi24

ous from the experience of the performances. However, the elasticity of health manpower growth with respect to health infrastructure is just about 0.70 (i.e., inelastic). This suggests that manpower growth is lagging behind infrastructure growth. Thirdly, public expenditure on the health sector seems to be inversely related to the rate of change in health infrastructure. If health infrastructure grows beyond the normal growth rate, then, public investment expenditures are cut. On the other hand, if the health infrastructure growth is lagging behind normal growth, then, public investment expenditures are enhanced. This seems to be prudent public finance management.

Linking the Performance, and Process Inputs of the Health Sector

Fourthly, change in health delivery (HP) is directly related to the levels of health manpower. In other words, development of health manpower is crucial for a good health delivery system.

Finally, the revenue expenditure at the state and central levels seem to be determined by considerations outside the health sector, as both health infrastructure and health manpower growth do not seem to explain the allocations.

25

Status of Health and Medical Care in India: A Macro Perspective

6
Production and Consumption Linkage Analysis of the Health Sector
Because of the multi-sectoral linkages referred to in Box 1, one can also analyse their interdependency linkages. However, data and information on all the aspects mentioned there are not available on a yearly basis (except for imports and exports). The CSO, an organ of the Ministry of Planning in the central government, has been compiling them for selected years. They are typically put in a matrix of commodity (including services) flow in value terms for a large number of sectors of the economy. This matrix is generally called ‘Input-Output Transactions Matrix’ of the economy. In the Transactions Matrix for the year 1993-1994, the economy is divided into 115 sectors. The sectoral linkage between the health related and other sectors of the economy are viewed in terms of value of various inputs into these sectors and presented in Tables 13 to 1614. In Table 14 only the most important and major inputs in value terms for the health and medical sector are shown. The input values are then converted into a ratio of the gross output (or total value of services from the health sector itself) to obtain an input/output coefficient. The coefficients then reflect the relative importance of the various inputs. For instance, it can be viewed that in 1993-1994, for every rupee of services provided by the health sector in India, the drug and pharmaceutical
14

inputs required were to the tune of Rs. 0.28. All the inputs can be interpreted in this way. The total inputs from all sectors taken together to provide one rupee of services from the health sector is Rs. 0.52. In a sense, this is an indicator of direct backward dependency of the health sector. This dependency was as high as 0.68 in 1973-1974. The direct input of material into the health sector seems to have been declining. The implication is that the manpower costs in the health sector have been increasing. Likewise, from Table 15, it can be seen that, in 1993-94, the direct backward dependency of the drug and pharmaceutical sector on all sectors of the Indian economy was to the tune of Rs. 0.66. Out of this, the inputs from the drugs and pharmaceuticals sector were Rs. 0.18. In the drugs and pharmaceuticals sector the direct inputs seem to be increasing over time from 0.52 in 1973-74 to 0.66 in 1993-94. Table 16 shows the import dependency of the two sectors for the most recent period. The import dependency of the health sector is quite minimal, amounting to only Rs. 0.015 per rupee of its service activity. The drugs and pharmaceuticals sector however, has a larger dependency on imports amounting to Rs. 0.078 per rupee of gross output. Several indicators can be computed to reflect the degree of linkages between the two sectors and all other sectors

These are presented in value terms, for the simple reason that at the macro-economic level, it is not easy and feasible to present the same in physical units such as kgs. of medicines, or litres of saline or thousands of syringes and so on.

26

Production and Consumption Linkage Analysis of the Health Sector

of the economy. They are based on the methodology of Input-Output Transactions Table, referred to above. Five major indicators used here are: Forward Linkage

Backward Linkage Total Direct and Indirect Linkage Direct and Indirect Inducement Total Linkage with Final Demands

Table 13: Backward, Forward, Total Production Linkage and Final Demand Linkage Indices - Service and Utility Sectors
1973-74 1989-90 1993-94 Total Direct & Indirect Linkage Effect Index 4.9506 0.4983 0.5854 1.6875 4.553 0.5524 1.0869 3.2556 1.0557 0.4948 0.5016 0.6348 2.5756 0.4948 0.8691 1993-94 Direct & Indirect Inducement Index 1.1063 0.6956 0.8043 0.9511 1.0074 0.7882 0.654 0.6089 0.6584 0.555 0.6045 1.0402 0.9551 0.4948 1.1859 Total Linkage Coeff. for final Demand (Relative) 0.322 0.0378 0.065 0.3291 0.0948 0.0004 0.1583 0.0351 0.0126 1.6076 1.0783 1 1.7309 1.3219 –

Sector

Forward Backward Forward Backward Forward Backward Linkage Linkage Linkage Linkage Linkage Linkage

Electricity Gas Water Supply Railway Transport Other Transport Storage & Warehousing Communication Banking Insurance Ownership of dwellings Education & Research Medical & Health Other Services Public Administration Trade Drugs & Pharmaceuticals

0.7662 0.0418 0.3685 0.524 0.4076 0.9949 0.3144 0.7398 0.3464 0 0.0001 0.0462 0.5362 0 1.058

0.5082 0.2304 0.308

0.917 0.3327 0.3626 0.6837

0.6199 0.5325 0.4481 0.4546 0.4295 0.2889 0.1752 0.2027 0.1189 0.1564 0.0923 0.5383 0.4059 0 0.6364

0.9084 0.0897 0.4768 0.689 0.5009 0.9908 0.6545 0.7817 0.9539 0 0.004 0.1178 0.4555 0 0.6024

0.6416 0.2668 0.2939 0.4488 0.5189 0.3184 0.1612 0.1471 0.1701 0.0553 0.1119 0.5157 0.2406 0 0.6532

0.3887 0.1922 0.1298 0.0606 0.0796 0.3281 0.6835 0.0625 0 0.4987

0.5135 0.9898 0.6682 0.8115 0.9544 0 0.0037 0.1249 0.6201 0 0.715

0.3613

0.1468

0.4673

0.267

0.4479

0.2333

5.9201

0.7221

Notes : Forward Linkage for sector i = j ∑ Xij /Xj ; Backward Linkage for j sector = i ∑ Xij / Xi Total Direct & Indirect Linkage Effect Index for sector i = n j ∑ Xij /∑ ∑ Cij Direct & Indirect Inducement Index for sector j = N i ∑ Xij /∑ ∑ Cij Total Linkage Coefficient for Final demand = (∑ Cij ) fj where: Cij are the elements of the inverse matrix { I- X}-1. and fj is the final demand for sector i Source: Input-Output Transactions Tables, 1973-74, 1989-90, 1993-94.

27

Rank

Status of Health and Medical Care in India: A Macro Perspective

28
Table 14: Changing Structure of Inputs into Medical and Health Sector (Rs. in Lakh) 1993-94 Value 288211 64287 19763 19333 14229 7407 5995 5803 5294 4085 4070 4039 3607 3422 2096 71 451712 All other inputs TOTAL INPUTS Gross Output 461836 461836 857896 0.0042 0.004 0.0024 0.0001 0.5265 0.5383 0.5383 All other inputs TOTAL INPUTS Gross Output 0.0047 0.0047 0.0048 0.0062 0.0068 Communication Milk & milk prods. Water supply Other chemicals Petroleum prods Other livestock prods Paddy Electrical appliances 0.007 Electricity Misc. manufacturing 0.0086 Construction 0.0166 Other services 0.0225 Medical & health 0.023 Other transport 0.0749 Trade 143118 91764 54817 33239 18724 8582 8548 7381 5726 5200 5121 4576 3870 3188 506 887927 906601 906601 1757861 0.336 Drugs & pharma 493567 Coeff. Sector Value Coeff. 0.2808 0.0814 0.0522 0.0312 0.0189 0.0107 0.0049 0.0049 0.0042 0.0033 0.003 0.0029 0.0026 0.0022 0.0018 0.0003 0.5051 0.5157 0.5157 1989-90 Value 55830 10870 3109 1582 1482 990 969 591 566 540 374 310 284 264 253 10 78024 1810 79834 116788 0.6836 0.0155 0.6681 0.0001 Electrical appliances 0.0022 Petroleum prods 0.0023 Paddy 0.0024 Wheat 0.0027 Railway transport 0.0032 Milk & milk prods. 0.0046 Hotels & restaurants 0.0048 Other services 0.0051 Construction 0.0083 Electricity 0.0085 Other crops 0.0127 Misc. manufac. 0.0135 Other transport 0.0266 Medical & health 0.0931 Trade 0.478 Drugs & pharma Coeff. Sector

1973-74

Sector

I

Drugs and pharma

II

Trade

III

Other transport services

IV

Communication

V

Other services

VI

Electricity

VII

Construction

VIII Other livestock products

IX

Misc. metal products

X

Railway transport serv.

XI

Misc. manufacturing

XII

Hotels & restaurants

XIII

Misc. food products

XIV Milk & milk products

XV

Other crops

XVI Electrical appliances

XVII Total of the Above

All other inputs

TOTAL INPUTS

Gross Output

Source : Input-Output Transaction Tables, 1973-74, 1989-90, 1993-94

Table 15: Changing Structure of Inputs into Drugs and Pharmaceuticals Sector (Rs. in Lakh) Value 246586 122625 92362 89247 51921 48859 47584 32070 19071 17422 14843 0.0121 Non-ferrous basic metals 0.0111 Misc. textile products 6035 5951 389839 All other inputs Total Input Gross Output 48461 438300 663104 0.0091 Other livestock products 0.009 Misc. manufacturing 0.5879 0.0731 All other inputs 0.661 Total Input Gross Output 12976 11137 9880 9333 825916 99635 925551 1391850 Coeff. 0.1772 0.0881 0.0664 0.0641 0.0373 0 0.0351 0.0342 0.023 0.0137 0.0125 0.0107 0.0093 0.008 0.0071 0.0067 0.5934 0.0716 0.665 1989-90 Value 5310 3368 3169 2786 newsprint 2170 1688 0 1574 1540 1416 0 1124 715 654 582 504 405 27005 3369 30374 58120 0.5226 0.058 0.4646 0.007 Plastic Products 0.0087 Nonferrous basic metals 0.01 Misc. Manufacturing 7368 0.0113 Sugar 8037 0.0123 Banking 9795 0.0193 0 0 0.0148 Forestry & logging Other Services 10870 0.0244 Inorganic heavy chemicals 11328 0.0265 Other transport 15301 0.0271 Forestry & logging 15375 0.0232 Banking 0.0231 Electricity 0.0171 Inorganic heavy chemicals 0.0164 Plastic products 0 newsprint 0.029 Electricity 18250 0.0373 Other Chemicals 23240 0.035 Other chemicals 0.0275 Paper, paper products & 25052 0.0378 0.0479 Paper, paper products & Other transport services 0.0545 Organic heavy chemicals 25316 0.0382 Organic heavy chemicals 0.0579 Trade 56606 0.0854 Trade 0.0914 Drugs & Medicines 151315 0.2282 Drugs & Medicines Coeff. Sector Value Coeff. Sector 1993-94

Rank

1973-74

Sector

I

Organic heavy chemicals

II

Trade

III

Drugs & medicines

IV

Inorganic heavy chemicals

V

Non-ferrous basic metals

VI

Other crops

VII

Other services

VIII

Other non-metallic minerals

IX

Other chemicals

X

Paper, paper products &

newsprint

XI

Other transport services

XII

Electricity

XIII

Banking

XIV

Plastic products

XV

Wood & wood products

XVI

Total of the Above

All other inputs

Total Input

Gross Output

Source : Input-Output Transaction Tables, 1973-74, 1989-90, 1993-94

Production and Consumption Linkage Analysis of the Health Sector

29

Status of Health and Medical Care in India: A Macro Perspective
Table 16: Imports into Health Related Sectors (1993-94) The definitions of these indi(Value in Rs Lakhs) cators and their computaS. No. Sectors Drugs & Coeff. Medical Coeff. tional methods are shown in Pharma& ceuticals Health Table 13 along with their es1 Other livestock products 885 0.0006 timates for the three distinct 2 Khandsari, boors 34 0.00002 periods under study, namely, 3 Miscellaneous food products 923 0.0006 1973-1974, 1989-1990 and 4 Wood and wood products 106 0.00007 1993-199415 . The question 5 Paper, paper prods. & newsprint 8364 0.0061 534 0.0003 before us is the role and rel6 Petroleum Products 2087 0.0015 1660 0.0009 evance of the health sector 7 Inorganic heavy chemicals 6091 0.0043 among major service sectors 8 Organic heavy chemicals 54812 0.0393 of the country. The Total 9 Paints, varnishes and lacquers 20 0.00001 Linkage Coefficient best an10 Drugs and medicines 25025 0.0179 swers this for Final Demand 11 Synthetic fibers, resin 149 0.0001 (computed for the year 199312 Other chemicals 4110 0.0029 94 only). For this purpose, the 13 Other non-metallic mineral prods. 6126 0.0044 14 Hand tools, hardware 322 0.0002 total linkage index in respect 15 Miscellaneous manufacturing 4067 0.0023 of Final Demands for the 16 Other services 20957 0.0119 health and medical care sec17 Public administration tor is set as a numeraire (i.e., Total Imports 109055 0.0783 27218 0.0154 unity). Then the relative indiGross Output 1391850 1757861 cators for several other serSource : Input-Output Transaction Tables, 1993-94 vices and utility sectors reflect their relative importance. Notice that except for education, other services and pubIn 1993-94 (the most recent year for which the I-O lic administration, all other sectors have very low final deTable data is available), the forward linkages of health mand linkages. and medical care sector are higher than for education.

Likewise, all the indicators can be compared across the sectors. Based on such a methodology the following major conclusions can be drawn. The forward linkage of the medical and health care sector has increased over time, whereas the backward linkage has declined. In the case of the drugs and pharmaceuticals sector, both the forward and backward linkages have been increasing.

The backward linkage for the health and medical care sector in the year 1993-94 is quite high as compared to education, insurance, other services or banking. The Direct and Indirect Inducement Index for the health sector is quite high (comparable to the transport sector, trade or electricity etc.) The drugs and pharmaceuticals sector has relatively high forward and backward linkages, compared to other services and utility sectors.

15

The choice of the three periods is simply based on the availability of Input-Output Transactions Tables

30

7
Conclusions
The analysis of sectoral linkages between the health and medical sector with other sectors of the economy (Section 6 in particular), ascertains that the health and medical sector seems to have assumed its rightful place in India. It plays a very important role in the social sector and in development in the context of the reforms process. The question as argued by Srinivasan (2000) is how to internalise it, rather than doing without it. In this study the health sector’s performance in India over the last two decades has been reviewed at the macroeconomic level. The major findings and the relevant policy options and corrections at the macro-economic level are summarised here. There is some evidence to say that the central budgetary allocations have not been reduced in the health sector, be it at the per capita level or per rupee of GDP or even as a ratio of total revenue budgetary allocations. In fact, invariably they have shown an increasing trend, however marginal it may be. Yet, the same cannot be said about the allocations of out-of-state revenue budgets. Clearly, the states budgetary allocations have declined, as a share of allocations out of the total revenue budget, remained fairly constant in terms of percentage of the GDP, but have shown a slow increase in per capita terms. Since health care delivery is a state subject in India, it is extremely important that states maintain their budget allocations to this vital sector at a rate of growth of at least five to six percent. The growth of health manpower and infrastructure is another matter of concern. The analysis shows that while the emphasis was heavily loaded in favour of infrastructure development in the 1980s, the same has shifted to manpower development in the 1990s. Economically it may be an efficient way of managing the development of the health sector in such a phased manner over the Plan periods, but such development at times will amount to having infrastructure, but no doctors and vice-versa. Certainly, such phasing of development of the two arms of the health sector may not be in the best interests of the people for whom health care delivery is important. It is important to maintain some kind of balance in the development of both infrastructure and manpower as health is more a matter of social relevance rather than economic relevance. In terms of policy, quite often, external funding drives such developments. The government should be more careful to see that the health care delivery system is not affected by the funding mechanisms. Finally, for better resource allocation and management, the link between the health sector and the rest of the economic sectors should also be kept in mind. The linkage analysis shows that the health sector’s backward linkage has been declining and forward linkage increasing. This will mean that the development of this sector will be dependent on the advancement of technology, inflow of foreign capital, imports of drugs etc. It is necessary to recognise the traditional and indigenous knowledge and techniques and find a place for them in development of the health sector. On the other hand, in the case of drugs and pharmaceuticals, over time, both the forward and backward linkages have been on the increase. Still, it is seen that rather than the backward
31

Status of Health and Medical Care in India: A Macro Perspective

linkage, it is the forward linkage which is quite high. Once again, the Indian drugs and pharmaceuticals sector is becoming more and more dependent on the export and import of foreign drugs, intermediaries and technologies. This may not be in the best interest of promoting this sector, particularly, with a large number of small-scale units in this sector. It is now time to take a close look at the National Health Policy 2002. The findings and observations made in this study are confirmed by this policy document: They have already recognised the following: Compared to China (24.9%) or Sri Lanka (45.4%), India spends just about 17.3 percent of total health expenditure on public health. The central budgetary allocation for health over the period 1990 to 1999, as a percentage of the total central budget has been stagnant at 1.3 percent, while that in the states taken together has declined form 7.0 percent to 5.5 percent. The annual per capita public health expenditure in the country is no more than Rs. 200. The National Policy document therefore, recommends an increase in central allocations to six percent of the GDP, with two percent of the GDP being contributed exclusively as public health investment.

That state governments are required to raise the allocation to seven percent of their budget till 2005, and later to eight percent. That uneven access to and benefits from the public health system need to be corrected. It is estimated that the shortfall in sub centres, primary and community health centres is going to be about 16 percent (as against the norms). Inadequate public health facilities are such that less than 20 percent of the population which seeks OPD services and less than 45 percent of that which seeks hospitalisation avail of such services in public hospitals. This reflects the imbalance in the development of the public health manpower and infrastructure in India. Accordingly, the policy document suggests that: Allocation on public health infrastructure be raised to 55 percent specifically in the primary health sector, 35 percent to secondary and 10 percent to tertiary sectors. Management of public health service outlets be handed over to NGOs and other institutions of civil society. It is this aspect of health cooperatives that the CMDR has been promoting on an experimental basis (Panchamukhi and Nayanatara 2004), as part of the action and policy research.

32

Annexure : Broad notional definitions and norms for setting up of Health Facilities
1. A PHC serves approximately 30,000 population. The PHC will be supplied with drugs worth Rs. 30,000 annually. (All India Norm). A PHC will have one doctor. Subcentres serve approximately 5,000 people the plains and 3,000 in hilly and tribal areas. A subcentre is managed by a Junior Health Assistant (Female), Junior Health Assistant (Male), (All India Norm). 2. A CHC serves 1 lakh population. Generally one CHC is attached to 4 PHCs. It is the policy of the government to upgrade all taluka level institutions to 30 bed hospitals and talukas located at sub-divisional headquarters to 50 bed hospitals. (All India Norm). 3. District Hospitals are at each district headquarters. The district hospital will have following specialists: Medicine Surgery Obstetrics and Gynaecology Paediatrics Orthopaedics Ophthalmology Ear, Nose and Throat Pathology and Bacteriology Skin and STD Radiology Anaesthesia Dental

33

Status of Health and Medical Care in India: A Macro Perspective

REFERENCES
Ahluwalia, I.J. and Little, I.M.D. 1998. India’s Economic Reforms and Development: Essays for Manmohan Singh. Delhi: Oxford University Press. Annigeri 2004. ‘Changes in Health Care Infrastructure, Manpower and Performance in three states during Economic Reforms’, in P.R. Panchmukhi (ed.), Economic Reforms and Health Sector in India, CMDR. Ashtekar, Shyam 1999. ‘China: Reforms and Health Care’, Economic and Political Weekly, 34(41), p. 2908. Baru, Rama 1995. ‘Mixed economy in health care: Some issues’, IASSI Quarterly, 14(1), p. 67. Berman, Peter 1996. ‘Health Care Expenditure in India’, in Monica Dasgupta et. al. (ed.), Health, Poverty and Development in India, 331-357. New Delhi: Oxford University Press. Bhagwati, Jagadish and Srinivasan, T.N. 1993. India’s Economic Reforms, Ministry of Finance, Government of India. Chauhan, Devraj and Kamdar, Sangita 1997. ‘Social sector and development: Focus on health care’, Yojana, 41(4), p. 13. Dasgupta, Monica; Chen, Lincoln C. and Krishnan, T.N. (ed.) 1996. Health, Poverty and Development in India. New Delhi: Oxford University Press. Diwan, R. 1995. ‘Economic Reform as Ideology’, Economic and Political Weekly, July, PE-73 to PE-86. Duggal, Ravi 1997. ‘Health care budgets and in a changing Political Economy’, Economic and Political Weekly, 32(20), p.1197. Editorial 1992. ‘Health Care Financing: Shutting out the Poor’, Economic and Political Weekly, 27(37), p. 1946. Guhan, S. 1996. ‘Social expenditures in the Union Budget 19911996’, Economic and Political Weekly, 30(18-19), 1095-1101. Joshi, Vijay and Little, I.M.D. 1996. India’s Economic Reforms 19912001. New Delhi: Oxford University Press. 34 Krishnan, T.N. 1996. ‘Hospitalisation Insurance: A Proposal’, Economic and Political Weekly, 31(15), 944-946. Malhotra, Santosh et. al. 1998. ‘Reallocating Public Spending for Basic Social Services in Developing Countries’, Economic and Political Weekly, 33(27), 1717-1724. Naidu, K.M., Manjushree, P. and Munirathnam, B. 1995. ‘Impact of Structural Adjustment on Poverty, employment, Income Distribution, Health Care and Education’, Indian Journal of Labour Economics, 38(4), p. 623. Oommen, M.A. 1993. ‘Bhagwati-Srinivasan Report on Economic Reforms’, Economic and Political Weekly, 29(12), p. 683. Panchamukhi, P.R. 2001. ‘Economic Reforms and the Health Sector: Analysis of the Nexus in the context of Karnataka’, in Arun P. Bali (ed.), Refashioning the New Economic Order: Karnataka in Transition, 302-349. Rawat Publications: Jaipur. Panchamukhi, P.R. and Nayanatara, S.N. 2004. ‘People’s Participation in Health: Pre-payment Mechanism through Health Care Co-operative’, in P.R. Panchmukhi (ed.), Economic Reforms and Health Sector in India, CMDR. Panikar, P.G.K. 1986. ‘Financing Health Care in China: Implications of some recent developments’, Economic and Political Weekly, 21(16), p. 706. Puttaswamaiah, S. 2004. Economic Reforms and Health Sector: Some Lessons from International Experience in P.R. Panchmukhi (ed.), Economic Reforms and Health Sector in India, CMDR. Rao, C.H.H. and Linnemann, H. (ed.) 1996. Economic Reforms and Poverty Alleviation in India. New Delhi: Sage Publications. Seeta Prabhu, K. 2001. Economic Reform and Social Development: A study of two Indian States - Strategies for Human Development in India, 3. New Delhi, Sage Publications. Seeta Prabhu, K. 1994. ‘The Budget and Structural adjustment with a human face’, Economic and Political Weekly, 19(16-17), 1011-1028.

References Sen Gupta, Amit 1996. ‘Economic reforms, health and pharmaceuticals: Conferring legitimacy to the market’, Economic and Political Weekly, 31(48), p. 3135. Shariff, Abusaleh; Gumber, Anil; Duggal, Ravi and Alam, Muneer 1999. ‘Health care financing and insurance: Perspective for the Ninth Plan 1997-2002’, Margin, 31(2), p. 38. Sharma, B.B.L. 1999. ‘Financing health care reforms: An overview of issues’, Indian Journal of Public Administration, 45(4), p. 763. Sisodia, Pratap 1993. ‘Public expenditure on health care through the state government of Rajasthan’, Finance India, 7(1), p. 33. Srinivasan, T.N. 2001. Eight lectures on India’s Economic Reforms. New Delhi: Oxford University Press. Sundar, Ramamani 1994. ‘Household survey of health care utilization and expenditure’, Margin, 26(4), p. 865.

35

About the Series Editors
Aasha Kapur Mehta is Professor of Economics at the Indian Institute of Public Administration, New Delhi and leads the Chronic Poverty Research Centre’s work in India. She has a Masters from Delhi School of Economics, an M.Phil from Jawaharlal Nehru University and a PhD from Iowa State University, USA. She has been teaching since 1975, initially at a college of Delhi University and then at IIPA since 1986. She is a Fulbright scholar and a McNamara fellow. Her area of research is now entirely focused on poverty reduction and equity related issues. Pradeep Sharma is an Assistant Resident Representative and heads the Public Policy and Local Governance Unit in the India Country Office of United Nations Development Programme (UNDP). A post-graduate from University of East Anglia (UK) and Doctorate from Jawaharlal Nehru University, he has held several advisory positions in the Government of India and has taught economic policy at LBS National Academy of Administration, Mussoorie. He has several publications to his credit. Sujata Singh is an Associate Professor at the Indian Institute of Public Administration. She completed her doctoral studies in Public Administration and Public Policy at Auburn University, USA. Her primary research interests are in the area of Comparative and Development Administration, Public Policy Analysis, Organizational Theory and Evaluation of Rural Development Programmes. R.K. Tiwari is Senior Consultant, Centre for Public Policy and Governance, Institute of Applied Manpower Research, Delhi. He was formerly Professor of Public Administration at the Indian Institute of Public Administration (IIPA), New Delhi. He received his education at Gwalior, Allahabad and Delhi. He has undertaken a number of research studies in Development Administration, Rural Development, Personnel Administration, Tribal Development, Human Rights and Public Policy. He has conducted consultancy assignments for the Department of Posts and in the Ministry of Rural Development, Government of India; and for the Government of Orissa and the Narmada Planning Agency, Government of Madhya Pradesh. He has published several books. P.R. Panchamukhi, is Professor Emeritus, Centre for Multi-disciplinary Development Research (CMDR), Dharwad, where he was Founder-Director. He has a doctorate in Pubic Finance from Bombay University. He has been awarded a number of coveted scholarships and prizes including Seth Mangaldas Jeshingbhai Economics prize for standing first in the Bombay University and V.K.R.V.Rao Award for significant original research contribution. He has held the CN Vakil Chair in General Economics of Bombay University and has worked as Director, Indian Institute of Education, Pune. He been Advisor to the Planning Commission and has served on a number of committees of Govt. of India, Govt. of Karnataka, and Maharashtra, and been a consultant/adviser to international agencies like The World Bank, UNICEF, UNESCO, Columbia University, WHO-Geneva, ESCAP-Bangkok, Indo-French Round Table. He has been Chief Editor /Editor of different national level journals. He has authored 15 major research works and has more than 89 research papers in national and international publications in the areas of Education, Health, Public Finance and Developmental Economics.

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